Monday, 20 February 2012

Out of hours GP work

Hi,

This week, despite being on my dermatology rotation still, I spend a lot of time with GPs, attending both the regular bi-weekly session which I have on rotation throughout this year, and a one off session with the out of hours GP service as well. This service is linked to GPs across the county, meaning after the surgeries close the calls are forwarded on to here, where the patients can then talk to GPs, or have GPs visit them at home if they are poorly enough. The patients I see in both surgeries, one in the day time one in the night time, seem to come in clumps by illness, which is strange. Perhaps this is the same phenomenon which causes buses to come in groups of three.

With the on call GP, the GP sits in a room in a hospital with a phone and a computer. Patients who are put through to the 'out of hours GP service', either by a forwarded call from a closed GP surgery or they can call the number directly after being given it by a service such as NHS direct. The calls are dealt with by some poor call-handler, who then puts them on the computer with information about the patient for the GP to call. This way the GP's time isn't wasted collecting address info and the such, and he perform a quick triage, calling the most important looking patients first. After calling and talking to them, the GP can either just reassure them, send a prescription to a nearby pharmacy by fax for them to collect, ask them to come into the hospital to see him (if they need to be examined) or (if they are really sick) arrange an immediate home visit. There are two GPs running this service, both carrying out this role, but one also has to go out in the car and visit the patients who need to be seen. I am not with this doctor, so don't see many home visits, but as the vast majority of calls ended up with the patient being asked to come into the hospital, I think I had the better deal.

The range of patients the GP had to deal with was pretty diverse, as you would expect from someone who works in primary care. The patients ranged from suspected breaks in bones and musculoskeletal injuries to sick children. The pace of the work was really nice. At times, working in the day at a GP surgery can feel very rushed as you have dozens of patients to see in one morning, meaning there is a very real time limitation on each consultation. Here it was very different. Patients were called up and talked to as much as needed, and then once they were bought in they coul talk with the doctor for as much time as the doctor wanted. I was there for more than 6 hours, and we only talked to about 12 patients, seeing most of them afterwards. At about 30 minutes a patient that is fantastic, and with the much smaller waiting times (basically none) I have no idea why people were bothering to attend the busy 3 hour wait A&E next door to us in the hospital! Its a shame the services aren't merged, though, as I am sure the GP could have seen many of the patients who come into A&E, giving him a little more work but taking a lot of pressure off of the A&E department. I suppose it wouldn't have been as much fun then, though!

The GP who I was working with was a fantastic man. 70 odd years old, he had retired from working as a partner in a GP practice, and now just did locum work, and the occasional out of hours shift for interest. He had been a bus driver in his youth, but had decided to work as a doctor and gone to medical school. As well as being a GP after graduating, he had done many other jobs, including setting up and running a small railway, running for parliament and competing in the world championships of a popular sport! Fantastic to see that its possible to combine medicine with a healthy life outside.

Being a GP is a little like running a one man band, but when you have all these things going on in your life outside medicine as well... !!

As I said before, the patients seemed to come in clumps of disease while I was working with this GP. First, there were a few children who had developed fevers, followed by a couple of people with labyrinthitis. This is inflammation of the inner ear, often caused by a viral infection, and can make people cripplingly dizzy. I don't know if there were a number of them because there is some kind of contagious virus going around, but I hope I don't get it. Being unable to get out of your bed without being sick from the vertigo does not sound much fun at all! Strangely, after that there were two patients (with one seen in between them) who had both come in having found a strange lump below their sternum. One had been prodding around his upper abdomen after a diagnosis of gastro-oesophageal reflux disease, the other had just found it while 'poking himself' (odd man). The diagnoses in both of these cases were that the 'lump' that was being felt was nothing other than the 'xiphisternum' a small jutting-out-bit below your sternum that everyone has, which can be hard or a bit gristly. I thought that the odds of one person deciding this normal part of anatomy was some disease and coming in were low, so the odds of two people on the same night deciding this independently was unbelievable. The GP tells me that this is quite a common mistake, and he has seen many people coming in with these 'strange lumps' in his time as a GP. Obviously they all do need to be examined (can't just tell them its fine over the phone in this case) as there are many other causes for lumps in the upper abdomen! Towards the end of the shift, there was a call from a paramedic, who had been called to someone's house who was very ill and had put them on oxygen (increasing saturations from 75% [very low] to 90% [still low]). The family of the person had decided that a DNR should be filled in, as this person seemed to be dying. A doctor needs to fill in one of these forms, so the car doctor was dispatched to the house in order to fill out the form, meaning that later, when the patient stopped breathing, he could just be left to die in peace. This is clearly a good idea, as if you die from something like cancer, resuscitation will not get rid of the cancer, and you will just die again, but it just seemed so businesslike and cold to me. Perhaps that is the way doctors try and conduct this sort of business, to try and remove themselves from the reality a little bit.

On the way home, I had to take the last train back, as my car is being fixed up. I hadn't had dinner as I had been on the shift over dinner time, so had grabbed some chips to eat on the train on my way to the station. I was in quite a poor area, and there were a couple of youngsters in Burberry wear on the platform drinking their Stella waiting to get the last train home as well. One started talking to me, saw my badge and then started goin on about how respectable it was that I worked in the NHS, and that his 'old ma' also worked in the hospital. He pulled the other over and started going on about how I, while their age, was going around saving lives all day. Very embarrassing and all far too fast. I don't go around saving lives all day at all - I am a medical student and just follow doctors around wasting their time. Unfortunately this praise had gone on too long for me to deny it now, so I just buried my head in my chips. The chap who had been pulled over was not impressed at all though, and slurred

"He doesn't work for the NHS, don't be a prat. Look. He's eating a kebab"

I wasn't really sure what to say to this, are healthcare workers not allowed to eat unhealthy food? And it was chips, not a kebab! I decided that laughing and shrugging was the least confrontational thing to do, but the first wasn't having any of it. He kept trying to get me to show his friend my badge to prove I worked in the NHS, but I didn't want them to look at it too closely as they would see I was only a medical student, and didn't actually work at all! Some cat and mouse ensued where I was flashing my badge to them (it was hidden under my coat, i bet this looked weird to the others on the platform), hopefully a little to fast for them to read it with their hazy vision. The friend was still unconvinced, due to my 'kebab cravings'. After ten minutes or so, the train arrived and I escaped to another carriage politely. The first guy still full of compliments, the second getting ready to start a fight with me or his friend. The fun times you have on trains!

You don't work for the NHS. You are eating a kebab!

The rest of my week was much calmer than this, with some time in dermatology again and the regular GP placement (hellish to get to without a car!). Here I got a lot of practice at orthopaedic examinations as a number of people came in with damaged shoulders (that grouping of illness presentations again. Odd). A couple of people had arthritis in their shoulder, one person had damaged the rotator cuff muscle doing sport, and the final patient had fallen during his work in a factory and was seeking compensation against the company. Once litigation is involved, the whole process becomes very careful, as GPs are well aware that lawyers may well want to read their notes. The man appeared healthy and seemed to be playing up a little during the examination, giving a mixed picture of pain. He wanted to be signed off from work for another two weeks as he said he was still too injured to work. The GP wasn't really sure if this was the case, and thought that perhaps he may be malingering. A hard call to make for a GP, who doesn't want to damage the relationship they build up with patients, but doesn't want to lie either. Perhaps this is where the government's "Work capability" assessment comes in useful, letting people be seen by healthcare professionals who are not their own, though I know there is opposition to it. In the end the GP decided to give him one more week of time off work and an urgent referral to the physiotherapist. The plan was that the next decision would be based on the physiotherapist's report, meaning that someone with much more expert knowledge than the GP could take a look, and in a small way, the GP would have more people backing up their decision to sent the patient back to work. This is important as well, as the GP tells me of patients who have gone back to work after arguments with their doctor and carried out tasks they know will injure them further, so they can try to sue the doctor as well. So cheeky!